*photo courtesy of Samrith Na Lumpoon via Shutterstock
Even if you’re not a committed athlete, you’ll probably be familiar with the ACL (anterior cruciate ligament). It’s the headline-making bane of many an elite sports star’s career. Tearing the ACL may not be the “career ender” it once was, but it’s still a serious injury and one that inevitably means months on the sporting sidelines in what remains a long road to recovery.
So you might be surprised to learn that, when you visit my Gloucestershire knee clinic to discuss your ACL tear, you might not need surgery at all. Not every ACL tear is the same. And not every person who tears their ACL will need to return to elite sport. A 17-year old who wants to play football will need their ACL. An office worker who has no intention of returning to skiing, tennis or anything else quite so active, may not. It’s possible, for some tears and some patients, that a combination of physiotherapy and strengthening of the muscles around the knee joint will enable them to get by without surgery.
For many, however, ACL surgery will still be necessary. And that begs the question, what sort of surgery?
ACL reconstruction or repair?
The ACL acts a little like the ropes that tie a boat to its moorings. It stops the knee joint from twisting too far when you pivot, keeping things in place and ensuring movement is limited to a safe range of motion. When a serious rupture occurs, the knee can feel unstable because one of the ‘ropes’ that help keep it steady has snapped.
You might imagine a repair would be the sensible option, but it’s not the case. The ACL attaches to the thigh bone (femur) and shin bone (tibia) and when it tears, it’s usually from its anchor point on the femur. You might have heard ligaments described as a bit like elastic bands, but that’s not really true. Tear an ACL and it will stretch before it snaps. Fix it back in place and it will remain deformed and laxer than it once was.
That’s one of the reasons ACL repair has a high level of failure in adults (things are a little different for children) and, to get the best chance of success, the repair surgery needs to happen very quickly, which often isn’t an option.
The alternative, for which there is far greater success, is ACL reconstruction.
ACL reconstruction involves taking some tissue from elsewhere (a graft), ‘plugging’ it into the femur and tibia, and using it as a sort of scaffold to support the ACL.
Which graft?
Surgeons have several options when making graft choices. Although patients do ask about them occasionally, we tend not to recommend synthetic grafts as they have a high rupture rate. Allografts can be effective, but require a donor. That leaves an autograft, which involves taking tissue from one part of a patient’s body and using it to form the new ACL. There are several candidates when it comes to tissue choice:
- Hamstring: The UK’s most common autograft choice, knee surgeons take tendons from the back of the knee and form them into a tube that becomes the new ACL.
- Patella tendon: This was once the most popular graft choice and it’s seeing a resurgence in popularity, most notably with professional footballers.
- Quadriceps tendon: Another popular option (and one I’ve used twice in the last couple of months).
You might wonder which is best, but the reality is each could be the best option depending on the patient and their expectations. In every autograft, a surgeon is removing tissue from one part of the body and that creates a deficit in that area. So the issue isn’t simply about which tissue is best for the graft, but which area of the body is best suited as a donor of the tissue. For example, using the patella tendon as graft tissue can lead to pain at the front of the knee. That means it may not be a good graft choice for people who spend a lot of time kneeling (if, for example, you’re a gardener or carpet fitter).
Then there’s the variation in the way each graft choice performs once it is part of the ACL. The patellar tendon tends to be a stiffer, more solid graft but the bone at either end of the graft helps it integrate more quickly. Hamstrings tend to be more forgiving, which makes them a good choice for people who take part in jumping sports.
Patient expectation also plays a big role in the choice of graft tissue. Patients will often have researched the type of graft they feel would be best for them by the time they visit my Cheltenham knee surgery. It’s certainly a discussion they’ll have with me before surgery.
ACL reconstruction for Cheltenham, Gloucester and the Cotswolds
Some ACL injuries are clear and obvious. There’s the hallmark popping sound, pain, swelling, and a feeling of instability. But not all ACL tears are obvious, especially once the initial swelling has subsided. That presents a problem, because swift diagnosis can be crucial for optimising recovery and reducing the risk of further damage.
If you’ve injured your knee, visit my knee clinic in Gloucestershire for swift diagnosis and treatment.
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